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U.S.NAVY 





VADM Willard P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADM H.A. Sparks, MC, USN 

Deputy Surgeon General 

Director of Public Affairs 

ENS Richard A. Schmidt, USNR 

Managing Editor 

Ellen Casselberry 

Assistant Editor 

Virginia M. Novinski 

Editorial Assistant 
Nancy R. Keesee 



Contributing Editors 
Contributing Editor-in-Chief : CDR E.L. 
Taylor (MC); Aerospace Medicine: 
CAPT M.G. Webb (MC); Dental Corps: 
CAPT R.D. Ulrey (DC); Education: LT 
R.E. Bubb (MSC); Fleet Support: LCDR 
J.D. Schweitzer (MSC); Gastroenterol- 
ogy: CAPT D.O. Castell (MC); Hospital 
Corps: HMCM H.A. Olszak; Legal: 
LCDR R.E. Broach (JAGC); Marine 
Corps: CAPT D.R. Hauler (MC); Medi- 
cal Service Corps: CAPT P.D. Nelson 
(MSC); Nephrology: CDR J.D. Wallin 
(MC); Nurse Corps: CAPT PJ. Elsass 
(NC); Occupational Medicine: CDR J.J. 
Bellanca (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Research: 
CAPT J. P. Bloom (MC); Submarine 
Medicine: CAPT R.L. Sphar, (MC) 



POLICY: U.S. Navy Medicine Ls an officii] publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. H disseminates to Navy Medical 
Department personnel official and professional informarion 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed arc those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau, of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U~S- ffuvy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Savy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical. Dental, Medical Service 
and Nurse Corps officer; one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command, 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor, U.S. Savy Medicine. Department of 
the Nayy, Bureau of Medicine and Surgery (Code 0010), 
Washington. D.C. 20372- Telephone: (Area Code 202) 254- 
425J, 254-4316, 254-4214; Autovon 294-4253. 294-4316. 294- 
4214. Contributions from the field are welcome and will be 
published as space permits, subject to editing and possible 
abridgment. 

The issuance of this publication is approved in accordance 
with Department of the Navy Publications and Printing 
Regulations (NAVEXOS P-35). 



U.S.NAVY 




Vol. 70, No. 1 
January 1979 



1 From the Surgeon General 

2 Department Rounds 

National Children's Dental Health Week . . . Dental Repair Tech 
School Relocated 

5 Safety 

6 Notes and Announcements 

8 Scholars' Scuttlebutt 
ACDUTRA Option: Orientation at Sea 
ENS W.M. Roberts, MC, USNR 

12 Instructions and Directives 

14 Features 

The Move to Micrographics 
LT P.A, Shannon, MSC, USN 

20 ACHA Admits New MSC Members 

23 First Regional Medical Record Meeting 

24 Diagnostic Data: A Key to Decision-Making 
CAPT J.J. Quinn, MC, USN 

22 NAVMED Newsmakers 

27 Professional 

Immersion Hypothermia 

LT W.C. Donehue, MC, USNR 

CDR E.L. Peters, NC, USN 

29 BUMED SITREP 



COVER: Again this year, Navy dental activities will be conducting 
special education and treatment programs in support of National 
Children's Dental Health Week, set for 4-10 February. During last 
year's observance, DT3 Joan Nelson captivated a student at Treasure 
Island (Calif.) Elementary School while applying topical fluoride. 



NAVMED P-506S 



From the Surgeon General 



The Key to Our Future 



The new year is upon us, and it is 
a time to look ahead. 1 feel it would 
be advantageous for us to take this 
opportunity to renew our personal 
interests in a pursuit that may have 
taken a back seat for one reason or 
another. That pursuit is research. 

Research is the key to our future. 
We as a Medical Department must 
maintain an active research pro- 
gram or be limited to a "catch-up" 
existence. 

As health care providers we sim- 
ply cannot provide the best care 
with a reactive attitude. We must 
forge ahead, pave new roads, over- 
come our present limitations, and 
take charge of the future. 

The best way to do that is by 
stimulating our inherent desire to 
question, probe, and explore the 
unknown through research. 

I would encourage every member 
of the Medical Department to par- 
ticipate whenever possible in any 
program that involves research. At 
the very least, keep up with the 
latest literature providing back- 
ground on the subjects most fre- 
quently confronted by, and of inter- 
est to, you. 

We have an extremely active and 
very fine group of research insti- 
tutes, labs, centers, and units 
located around the world. They 
have been instrumental in providing 



positive solutions to some long- 
standing problems. 

I urge you to take advantage of 
these facilities, and the information 
made available by them, for projects 
of your own. 

Everyone cannot devote all of his 
or her time to engaging in pet 
projects. However, if you have an 
idea, explore it as far as you are 
able, and then pass it on for further 
development. 

The present philosophy, com- 
monly held by many, seems to be: 
Let's get through today and worry 
about tomorrow when it comes. 
Fortunately, we in Navy medicine 
have never had to contend with this 
attitude. We have always looked 
ahead. 

This coming year promises to 
hold even bigger developments in 
all areas of Navy medicine, and par- 
ticularly research. It should be a 
banner year, and with additional 
emphasis on personal research it 
can be nothing less. 

My best wishes for 1979. 





W.P. ARENTZEN 

Vice Admiral, Medical Corps 

United States Navy 



Volume 70, January 1979 



Department Rounds 



During National Children's Dental Health Week, 
the Navy will again be doing its part in 

Making America's Youngsters Smile 



Navy dental officers and dental 
technicians are gearing up for 
special activities in support of Na- 
tional Children's Dental Health 
Week, scheduled this year for 4-10 
February. 

The annual observance is spon- 
sored by the American Dental Asso- 
ciation to encourage good oral 
health habits among the nation's 
youngsters. In support of the ADA 
initiative, Navy Medical Depart- 
ment members at home and over- 
seas will, wherever possible, be 
conducting dental education and 
treatment programs for the children 
of Navy and Marine Corps members 
— so long as these programs do not 
interfere with the primary mission 
of providing care to active-duty per- 
sonnel. As in previous years, these 
special programs will usually be 
conducted during off-duty hours, to 
enable the largest possible number 
of children and parents to partici- 
pate. 

The theme for National Chil- 
dren's Dental Health Week this 
year will again be "Smile, Amer- 
ica!" and ADA recommends that 
educational activities during the 
week promote proper brushing and 
flossing, use of fluorides, and regu- 
lar dental visits. This year's obser- 
vance, however, will place special 
emphasis on the relationship be- 
tween good nutrition and dental 
health. Posters from ADA ("Sweet 



snacks, no . . . sweet smiles, yes") 
stress the importance of proper 
snacking habits — i.e., substitution 
of healthful fruits and vegetables 
for gooey treats. 

In past years, Navy dental activi- 
ties have been ingenious in devising 
programs for children that entertain 
as well as educate. Devices used 
have included skits, films, slide 
shows, demonstrations, and art con- 
tests on dental health subjects, in 
addition to examination of teeth and 



application of topical fluorides. Gift 
packs given away to children have 
included toothbrushes and tooth- 
paste, disclosing wafers, dental 
floss, and even disposable plastic 
mirrors. 

With appealing teaching tech- 
niques, Navy dentists and dental 
technicians have started many thou- 
sands of children down the road to 
oral health. This year, they'll be at 
it again, going all out to add to that 
number. 




A little horseplay helps 



U.S. Navy Medicine 




'Here's how they work . . .' 

Volume 70, January 1979 



A poster winner 



Dental Repair Tech School Relocated 



The Dental Repair Technology, 
Class C School (course number 
B- 198-00 13)— formerly located at 
NRDC Norfolk, Va.— has completed 
its move to the Naval School of 
Dental Assisting and Technology 
(NSDAT) facility in San Diego, 
Calif. 

The school has recently converted 
to a modularized, task-based course 
of instruction. Skills taught include 
applied physics; installation, main- 
tenance, and repair of dental oper- 
ating room and prosthetics labora- 
tory equipment; accounting and 
financial management; and basic 
personnel and office management 
techniques. 

Certain parts of the course are 
taught as "common core" modules 
with the Dental Assistant, Ad- 
vanced, and Dental Laboratory 
Technology, Advanced, Class C 
Schools. These modules — which in- 



clude Speech and Instructor Train- 
ing, Logistics, Enlisted Evaluations, 
and Manuals and Publications — are 
designed to enable graduates to 
function more effectively as senior 
petty officers. 

Upon satisfactory completion of 
the "common core" items, students 
receive an intensive course in the 
dental repair specialty, including 
both classroom instruction and on- 
the-job application of skills. Work- 
ing under supervision of the NSDAT 
teaching staff and the staff of the 
Repair Department of NRDC San 
Diego, trainees are exposed to a 
variety of dental equipment and a 
range of dental repair situations. 

The school has facilities for a 
maximum of 6 students for each 6- 
month class. The present facilita- 
tor/student ratio is 1:6, affording 
maximum opportunity for individ- 
ualized instruction. 



The staff of the Dental Repair 
Technology School is augmented in 
specific modules by staff members 
of the Dental Assistant, Advanced, 
Class C School, ensuring that the 
information presented is accurate 
and up-to-date. In addition, many 
short courses presented by manu- 
facturers of dental equipment ex- 
pose trainees to the latest develop- 
ments in dental equipment tech- 
nology. 

Graduates of the Dental Repair 
Technology, Class C School earn the 
NEC 8732 and have the opportunity 
for assignment with the Fleet Ma- 
rine Force, at selected overseas sta- 
tions, and at naval regional dental 
centers. 

Interested personnel should con- 
tact their Educational Services Of- 
fice or their career counselor for 
information on admission require- 
ments and application procedures. 




DT1 Anderson (left) is explaining the mechanics of a dental operating unit to DT1 Mustain and DT2 Otto. 

4 U.S. Navy Medicine 



Safety 



Otto Fuel II is a red -orange liquid torpedo fuel with a 
distinctive odor. Personnel who inhale it or contaminate 
their skin during torpedo fueling and maintenance op- 
erations may suffer serious toxic effects — problems 
that can be prevented by proper ventilation and the use 
of protective clothing. 

The systemic absorption of OF II primarily causes 
acute cardiovascular changes. PGDN (1,2 propylene 
glycol dinitrate), the physiologically active component 
of the fuel, causes acute vasodilation. Nasal congestion, 
headaches, dizziness, nausea, and fainting may occur. 
Nitrated esters may convert hemoglobin into met- 
hemoglobin, but in OF II intoxication the levels of met- 
hemoglobin are not seriously elevated. 

Workers who absorb a physiologically significant 
dose of OF II by inhalation or skin absorption complain 
of headache, often throbbing in nature, on the first few 
days of exposure. Tolerance then develops, and the 
headache disappears as long as exposure continues. 
When the worker returns to his job after a weekend 
without exposure, however, the first contact with OF II 
again produces headache. The presence of a narrow 
pulse pressure, due to elevated diastolic pressure, is a 
physical sign that supports a diagnosis of headache due 
to OF II. A second common sign of OF II toxicity is 
sudden loss of consciousness, usually due to orthostatic 
hypotension. The over-exposed worker passes out but 
recovers rapidly when removed from exposure. 

Controlled chamber exposures have been conducted 
to determine the air levels of OF II that will not result in 
detectable detrimental effects on human health. 
Human responses to varying concentrations revealed 
that the first subjective effect was onset of mild head- 
ache — usually frontal in location. It was characterized 
initially as a feeling of pressure, followed by throbbing. 
Nasal congestion was not a problem and was reported 
only occasionally. 

A few of those tested developed a mild headache with 
an eight-hour exposure to concentrations of OF II as low 
as 0.1 ppm. The majority of individuals developed a 
headache after exposure to 0.2 ppm for as little as four 
hours. A few were able to tolerate one-hour exposures 
to concentrations of 0.35, 0.5, and 1.5 ppm; however, 
exposure for longer periods resulted in headache. Ex- 
posure to OF II at 0.5 ppm for six hours resulted in the 
onset of severe disequilibrium. The subjects were un- 
able to perform a modified Romberg test or a normal 
heel-to-toe test. At this point, they generally had severe 
headache but, if properly motivated, still possessed 
good manual coordination and were able to function 
intellectually. Exposure to OF II at 1.5 ppm caused on- 
set of definite eye irritation, without conjunctivitis or 
excessive lacrimation, after 30-40 minutes. 



Skin absorption of OF II may cause headaches, dizzi- 
ness, and nausea. Overexposure can result from exces- 
sive skin contact. Since the effects of long-term expo- 
sure are not known, skin contact should be avoided. 
Contamination of skin can be identified by yellow dis- 
coloration . 

OF II splashed into the eyes may cause severe irrita- 
tion, and exposure to vapor may also produce eye irrita- 
tion. Ingestion of OF II may cause disorders of the gas- 
trointestinal tract and mucosal membranes, dilation of 
blood vessels, headaches, nausea, and dizziness. Al- 
though ingestion is unlikely to occur under normal 
working conditions, it could result in death. 

Treatment of OF II toxicity consists in removal of the 
individual from exposure. Contaminated clothing 
should be removed and the skin flushed with water. 
There is no antidote; therefore, treatment of severe 
manifestations is symptomatic and supportive. 

BUMEDINST 6270.7A, Otto Fuel II Health Precau- 
tions, requires that personnel exposed to OF II have 
preplacement and periodic health examinations. These 
examinations must include, as a minimum, a medical 
history with emphasis on the presence of cardiovascular 
disease, hypotension or hypertension, and frequent 
severe headaches. Each worker should have a compre- 
hensive occupational history detailing prior exposure to 
any toxic gases, dusts, fumes, or chemicals. 

Physical examination should place special emphasis 
on the cardiovascular and neurological systems. Liver 
function tests, complete blood count, BUN, and urinaly- 
sis are recommended but not required. A resting 12- 
lead EKG should be performed, and an exercise EKG, 
if indicated by the examining physician. 

Medical personnel assigned to ships or facilities per- 
forming operations with OF II should regularly observe 
work areas to ensure that health precautions are ob- 
served. Local exhaust ventilation to control fuel vapor 
at its source is required in all operations involving OF 
II. For short-term emergencies, such as a spill, workers 
should use air-supplied respirators. 

Workers should have clean, disposable coveralls and 
a neoprene apron. Hand protection is required. BU- 
MEDINST 6270.7A lists disposable safety clothing 
available in the supply system. Face shields or chemical 
worker's goggles should be worn to prevent eye injury. 

No eating, drinking, or smoking should be permitted 
in OF II handling areas. Workers should wash their 
hands before eating, drinking, or smoking after leaving 
the area. 

In the event of a large spill, all personnel should 
evacuate the area until they can put on approved respi- 
ratory protective devices and appropriate protective 
equipment. 



Volume 70, January 1979 



Notes & Announcements 



In memoriam . . . CAPT Edmund H. Frizzell, DC, USN 
(Ret.), died 20 Nov 1978, at age 63. He was born in 
Poplar Bluff, Mo., and graduated from Northwestern 
University, CAPT Frizzell was a member of the Retired 
Officers Association. 



Dental continuing education courses . . . The following 
dental continuing education courses will be offered in 
April 1979: 

National Naval Dental Center, Bethesda. Md. 
Occlusion 2-4 April 1979 

Fleet and Marine Support Operational 

Management Seminar 16-20 April 1979 

Maxillofacial Prosthetics 30 April-2 May 1979 

Eleventh Naval District, San Diego, Calif. 

Oral Surgery 2-6 April 1979 

Preventive Dentistry and 

Patient Motivation 23-26 A pril 1 979 

U.S. Army Institute of Dental Research, Walter Reed 
Army Medical Center, Washington, D.C. 
Oral Diagnosis and Therapeutics 2-5 April 1979 

Letterman Army Medical Center, San Francisco, Calif. 
Oral Surgery 30 April-3 May 1979 

Requests for courses administered by the Comman- 
dant, Eleventh Naval District, should be submitted to: 
Commandant, Eleventh Naval District (Code 37), San 
Diego, Calif. 92132. Applications for other dental con- 
tinuing education courses should be submitted to: Com- 
manding Officer, Naval Health Sciences Education and 
Training Command (Code 5), National Naval Medical 
Center, Bethesda, Md. 20014. Applications should 
arrive six weeks before the course begins. 



Continuing education for Navy nurses . . . The Naval 
Health Sciences Education and Training Command will 
sponsor the following continuing education courses for 
Navy nurses: 

Development of a Personalized System of Learning (18 contact hours) 
Bethesda, Md. 2-4 April 1979 

New approaches to continuing education will be presented, with pri- 
mary focus directed toward a comparison of a personalized system of 
instruction (PSI) model with different types of programmed instruc- 
tion formats. The program is intended for those individuals involved 



in planning and developing continuing education and patient educa- 
tion projects. 

Essentials of Senior Nursing Management (30 contact hours) 

Bethesda, Md. 9-13 April 1979 

This workshop is scheduled for selected senior Nurse Corps officers 
to update information and skills in executive management relating to 
leadership, decision-making, budgeting, and personnel relations. 

The courses are open to Nurse Corps officers not cur- 
rently assigned to an oversea billet. However, nurses 
assigned to Argentia, Newfoundland; Bermuda; Guan- 
tanamo Bay, Cuba; Keflavik, Iceland; and Roosevelt 
Roads, Puerto Rico, who have served at least six 
months on active duty, may apply. The courses are also 
open on a space-available basis to Nurse Corps officers 
of the inactive Reserve. 

Nurse Corps officers wishing to attend these courses 
should apply to the Naval Health Sciences Education 
and Training Command (Code 7), National Naval Medi- 
cal Center, Bethesda, Md. 20014, following procedures 
set forth in the BUMED Instruction 4651.1 series. Ap- 
plications should be submitted four to six weeks before 
a course begins. 



AF1P course offered . . . The Armed Forces Institute of 
Pathology will offer the following course: 

Research Methods for Cytologists 23-27 April 1979 

Pathologists, cytopathologists and cytotechnicians are sometimes 
confronted with problems concerning the pathology-biology of single 
cells they wish to investigate; however, their educational back- 
grounds may not have equipped them with more than superficial 
knowledge of the tools for carrying out a research investigation. Some 
of the most commonly used of these tools will be presented in theory 
and in practical instructions. Topics include Phase and Normanski in- 
terface contrast; methods for measuring size and volume; fluores- 
cence methods in microscopy and flow-through devices; immunologic 
methods; tissue culture; and scanning and transmission electron 
microscopy. The course will help the participant to understand the 
scientific methods of carrying out an investigation with limited objec- 
tives and familiarize him with the more common means available 
today for the investigation of single cells. 

For further information write to the Director, Armed 
Forces Institute of Pathology, ATTN: AFIP-EDZ, 
Washington, D.C. 20306. 



Alcoholism indoctrination course . . . The Naval Alcohol 
Rehabilitation Center, Jacksonville, will offer a series 



6 



U.S. Navy Medicine 



of alcoholism indoctrination courses for physicians, 
nurses, psychologists, and other professionals and 
paraprofessionals. The course has been approved for 
80 hours of continuing medical education credit in Cate- 
gory I, The sessions will take place on the following 
dates: 



12-23 Feb 1979 
19-30 March 1979 
16-27 April 1979 
14-25 May 1979 



4-15 June 1979 
16-27 July 1979 
13-24 Aug 1979 
17-28 Sep 1979 



Names of nominees to attend the course should be 
submitted seven days before the class begins. For fur- 
ther information write to: Commanding Officer, Naval 
Alcohol Rehabilitation Center, Jacksonville, Fla. or call 
Autovon 942-3473, Commercial (904) 772-3473, 



Residency and fellowship training . . . The following 
medical residency and fellowship training programs 
will be available during FY 1979: 



Specialty 


Year Level (After 


Residencies 




Anesthesia 


First and Second 


Family Practice 


First 


Internal Medicine 


First and Second 


Obstetrics and Gynecology 


First 


Orthopedics 


First 


Otolaryngology 


First 


Pathology 


First and Second 


Pediatrics 


First 


Psychiatry 


First 


Surgery 


First 


Fellowships 




Infectious Disease 


First 


Maternal Fetal Medicine 


First 


Pulmonary Medicine 


First and Second 



Interested Medical Corps officers serving in fleet, 
operational/utilization tours should apply in accordance 
with BUMEDINST 1520. 10G of 12 May 1976. 

Applications for these programs should be submitted 
no later than 16 Feb 1979 to: Commanding Officer, 
Naval Health Sciences Education and Training Com- 
mand (Code 4), National Naval Medical Center, 
Bethesda, Md. 20014. 



Preventive and occupational medicine coarse . . . The 

second annual Review Course in Preventive and Occu- 
pational Medicine, will be held 28-31 March 1979, at 
the Drake Hotel, Chicago, 111. The continuing education 
course is co-sponsored by the American College of 
Preventive Medicine and the Cook County Hospital 
Division of Occupational Medicine in the Department of 
Medicine, and is designed for physicians, nurses, and 
other health professionals. 

The course will review core knowledge and highlight 
recent advances in the basic disciplines of general pre- 
ventive medicine and occupational medicine. Partici- 
pants are expected to improve their performance on 
Parts I and II of the certifying examination of the Amer- 
ican Board of Preventive Medicine. Each participant 
will receive a packet of pre-conference study materials. 
Optional problem-solving workshops will be available 
in the evenings. The course is certified for 32 credit 
hours in Category I. Tuition for the course will be $225 
(luncheons included) for attending physicians and $125 
for members of the American College of Preventive 
Medicine, resident physicians, nurses, or two-day-only 
(preventive medicine or occupational medicine) partici- 
pants. 

For further information write to: Review Course Co- 
ordinator, Division of Occupational Medicine, Cook 
County Hospital 720 S. Wolcott, Chicago, 111. 60612. 
Telephone (312) 633-5310. 



Fellowships in infectious diseases ... The Infectious 
Diseases Division, Department of Medicine, National 
Naval Medical Center, Bethesda, invites applications 
for fellowships in infectious diseases. 

The two-year program will consist of clinical, labora- 
tory, and research experiences in all fields of infectious 
disease, including tropical infectious diseases, and 
meets the requirements for the American Board of In- 
ternal Medicine examination in infectious diseases. The 
candidate may emphasize tropical medicine, with part 
of the training including a didactic course at Walter 
Reed Army Institute of Research and an experience at 
Gorgas Memorial Laboratory in Panama. Other clinical 
research may be arranged pending available resources. 

Candidates must have completed 36 months of post- 
graduate clinical training in internal medicine. For 
further information contact the Chairman, Department 
of Medicine, National Naval Medical Center, Bethesda, 
Md. 20014. 



Volume 70, January 1979 




U.S. Navy Medicine 



Scholars' Scuttlebutt 



ACDUTRA Option: Orientation at Sea 



ENS William M. Roberts, MC, USNR 



"Now set the special sea and 
anchor detail." 

It was to these words, authorita- 
tively transmitted over the ship's 
public address system, that I awak- 
ened in the gray dawn on 10 June 
1977, I clambered down from my 
upper bunk, hastily donning my 
work khakis and making my way 
topside to view our departure from 
Pier 12 at the Norfolk Naval Station . 

1 was one of four Medical Corps 
subsidy program students (1975 
program) who had opted for an 
at- sea orientation cruise as our 
annual 45-day ACDUTRA period for 
FY 1977. We had gathered in Nor- 
folk on the last day of May from 
diverse locations (Stan Napierkow- 
ski from Philadelphia, Jeff Krebs 
from Missouri, David Sneed from 
Texas, and I from Washington, 
D.C.), and had reported to CINC- 
LANTFLT. There we were informed 
that we would be assigned to the 
USS America (CV-66) soon to depart 
for the South Atlantic — destination: 
Rio de Janeiro, Brazil. 

Our excitement as we came 
aboard the huge carrier — close to a 
quarter of a mile in length, 18 decks 
tall, and home for nearly 5,000 men 
and 100 aircraft — cannot be de- 
scribed. 

A bit of mystery, and then gnaw- 
ing apprehension, set in as we were 

The USS America enters Guanabara 
Bay. 



repeatedly asked if we had ever 
"crossed The Line." Stan was at 
ease with his affirmative response, 
but the rest of us, upon answering 
no, were greeted with knowing 
grins. Only later were we to find out 
what lay in store for those whose 
previous travels had not included a 
transequatorial passage. 

Our carrier, the America, was one 
of five ships in a task force that also 
included the guided missile cruiser 
South Carolina; the oiler Neosho; 
and two destroyers, the Dupont and 
the Ricketts. The purpose of the 
task force visit to Brazil was to serve 
as a show of U.S. friendship, im- 
mediately following First Lady 
Rosalynn Carter's South American 
tour. During the course of the 
cruise, maneuvers with Brazilian 
aviators (whose single carrier was 
undergoing repairs) would take 
place. 

The four of us had been assigned 
a shipboard line advisor, and — once 
settled down after the initial excite- 
ment and confusion of getting under 
way — we began to follow a rota- 
tional schedule designed to acquaint 
each of us with the operation of an 
aircraft carrier at sea. We were 
given briefings in various depart- 
ments of the ship: Intelligence, 
Weapons, Engineering, Aviation, 
and Navigation, to name but a few. 
In addition, each of us stood 
watches on the navigation bridge, 
from which the movement and 



course of the ship are controlled; in 
PRIFLY, the aviation "control tow- 
er"; and below, in the ever-dark- 
ened surface and air surveillance 
control centers. 

The navigation bridge and PRI- 
FLY, both located high above the 
flight deck and the ocean, afforded 
incredible views of the sea dotted 
with vessels for miles around — and 
of the fascinating and intricate 
flight operations originating and 
terminating on the deck below. One 
unique experience for us was first- 
hand observation of at-sea refuel- 
ing, an immensely complicated and 
precarious maneuver refined to 
perfection by the U.S. Navy. 

Of obviously great interest to the 
four of us was the Medical Depart- 
ment, staffed by four doctors (a 
senior medical officer, a surgeon, 
and two flight surgeons), a Medical 
Service Corps officer, and approxi- 
mately 30 corpsmen (including 
three chiefs). The department had a 
30-bed ward, a four-bed isolation 
ward, an emergency room, an op- 
erating room, a laboratory, an X-ray 
unit (with the capability for contrast 
studies, such as the IVP), and a 
pharmacy. 

When not otherwise occupied, we 



ENS Roberts is a fourth-year Navy scholar- 
ship student at The George Washington Uni- 
versity School of Medicine in Washington, 
D.C. He will be starting his GME-1 year in 
basic surgery next July at NRMC San Diego. 



Volume 70, January 1979 



9 



were encouraged to involve our- 
selves in the operation of the de- 
partment. Helping out with morning 
sick call (at which, frequently, more 
than a hundred men would present 
themselves in a single morning) and 
working in the E.R. gave us an ex- 
cellent primary-care exposure and 
introduced us to some of the pecu- 
liar occupational hazards encoun- 
tered in life at sea: heat rashes 
suffered by men who worked in the 
intensely hot environment of Engi- 
neering; low back pain and other 
orthopedic complaints, often result- 
ing from repeated climbs and 
descents on the steel ladders con- 
necting the innumerable decks of 
the ship; cellulitis and other infec- 
tions, certainly in large part a 
product of the crowded living condi- 
tions; respiratory infections, which 
threatened to ground the aviators 
who contracted them; lacerations 
and soft-tissue injuries incurred in 
accidents; and the ever-present 
emotional problems of men away 
from family and other loved ones. 

As novel and engrossing as our 
shipboard activities were, it soon 
became impossible to contain our 
excitement — and, yes, apprehen- 
sion — as the day of our initiation 
drew near. Florid rumors of the 
atrocities we would encounter as we 
crossed The Line were rampant, 
and the malaise experienced by the 
great majority of the ship's com- 
pany (less than 10% of whom had 
previously traversed the equator, 
thereby qualifying as "shellbacks") 
grew as the shellbacks held secret 
gatherings in preparation for our 
initiation. 

Reveille was at 0530 as Davy 
Jones and King Nepture and his 
Royal Court came aboard. The 
skull-and-crossbones was raised 
high above the ship, and we lowly 
"pollywogs," clad in T-shirts and 
castaway trousers, were hustled off 
to a segregated breakfast of horrid 
green eggs. Then, department by 
department, we were called to ini- 
tiation. Each group assembled in 
the hangar bay, to be greeted by 
evil-looking shellbacks dressed and 
made up as Barbary pirates. Coaxed 



by the rattans wielded by our 
tormentors, we were immediately 
commanded to begin a very pro- 
tracted duck-walk out onto one of 
the large aircraft elevators. 
Clenched tightly between the teeth 
of each of us was the crucial sum- 
mons detailing alleged "crimes" 
against the Royal Court. 

In the bright sunshine out on the 
elevator, we were suddenly 
drenched by a downpour from 
powerful hoses aimed at us from the 
flight deck above. Still crouching on 
the elevator, we were transported 
slowly to the flight deck, where a 
terrifying sight greeted us: in- 
numerable "pirates," sporting 
wicked grins, awaiting our passage 
through their gauntlet. Each "stop" 
along our duck-walk path was worse 
than its predecessor: the double line 
of whip-wielding shellbacks by 
whom we had to crawl; the garbage 
chute through which we slithered; 
the Royal Dentist, who cheerfully 
irrigated our mouths with the 
foulest imaginable concoction; the 
Royal Barber, who threatened to 
scalp us and did perform an occa- 



sional uncomplimentary coiffure on 
various "special cases"; the Royal 
Court, at which we were each tried 
for our heinous crimes; the Royal 
Baby, in whose ample belly, 
smeared with kitchen grease, we 
were compelled to bury our heads. 

Finally, there was a welcome sea- 
water shower, and then the inevita- 
ble interrogation: "What are you?" 
Failure to respond "Shellback!" 
loudly enough compelled the of- 
fender to pass through the entire 
ordeal again. Several hours and 
several thousand initiations later, 
the good ship America had got rid 
of its pollywog vermin: we were all 
deemed worthy to be numbered 
among the distinguished shellback 
order — as was attested later by a 
truly handsome diploma and wallet 
certificate. 

Thus cleansed, the America 
plowed southward toward her first 
destination: Salvador, Brazil. Flight 
operations continued day and night, 
and I never ceased to marvel at the 
complexity and beauty of the events 
taking place on and over the flight 
deck, as well as at the precision, 




initiation rites for first-time crossers of "The Line" were fiendish and ingenious. 



10 



U.S. Navy Medicine 




Flight operations were not the least oi the cruise's fascinations. 



skill, and daring of the pilots and 
shipboard personnel. We medical 
students were given the opportunity 
— of which we hastily availed our- 
selves — to ride in one of the prop 
planes, the C.O.D. ("Carrier-On- 
Delivery") aircraft. The thrill of the 
deck run or catapault launch — not to 
mention the landing and abrupt de- 
celeration, courtesy of powerful ar- 
resting cables — will always be with 
me. High in the blue sky, gazing 
upon the tranquil waters of the 
South Atlantic and the tiny ships 
that made up our task force below, I 
experienced a sense of euphoria 
unmatched in the reality of my other 
new encounters. 

The day prior to the America 's 
arrival in Salvador, 1 once again 
boarded the C.O.D. , and we headed 
for the Brazilian city as part of an 
"advance guard." We thus had a 
chance to explore this capital of 
Bahia before the invasion of several 
thousand Americans: the quaint old 
fishing harbor; the beautiful, un- 
crowded, coconut-tree-fringed 
beaches; the old city built into a 
rocky crag; the excellent and rea- 



sonably priced restaurants; and the 
famous Mercado Modello, where 
innumerable merchants sold every 
imaginable product from wood carv- 
ings to leather goods to batida, a 
delicious Brazilian beverage avail- 
able in myriad fruit flavors. 

Members of the Brazilian naval 
air wing, including a Brazilian flight 
surgeon, boarded the America to 
share with us the short journey 
down to Rio de Janeiro. En route, 
we participated in joint flight opera- 
tions and thoroughly enjoyed get- 
ting to know our South American 
counterparts. 

June 28 dawned cloudlessly, and 
I was up early on deck to anticipate 
our arrival in Rio. 

Our five ships were an imposing 
sight with their crews manning the 
rails. Following a 21 -gun salute, we 
dropped anchor, and 1 could hardly 
contain myself as I waited for one of 
the ship's boats to ferry me ashore 
for the start of seven memorable 
days in one of the truly great cities 
of the world. 

Our spellbinding cablecar ride to 
the summit of Sugarloaf Mountain; 



an erratic taxi excursion up a steep, 
hairpin-curve trail to the Corcovado, 
with a breathtaking vista of all of 
Rio at sunset (followed by a hair- 
raising ride down, during which our 
driver refused to employ his 
brakes); a crazy soccer game be- 
tween Brazil and France at the 
world's largest stadium, whose 
playing field is surrounded by a 
moat to prevent irate fans from ad- 
judicating the contest; delicious 
meals every night at bargain prices; 
exciting and novel nightlife; shop- 
ping for gems from some of the 
world's most beautiful selections; 
jogging the length of the Copaca- 
bana at dawn — these and countless 
other memories mean Rio to me. 

Additionally, while we were in 
port an occasional night in the 
Emergency Room gave us a first- 
hand exposure to the vast array of 
minor emergencies commonly suf- 
fered by men on liberty. 

The day following a patriotic 
Fourth of July celebration in Guana- 
bara Bay — with the entire crew 
fondly treasuring memories of a 
great liberty port — we set sail for 
home, not stopping along the way, 
but passing within easy view of the 
lovely Caribbean islands of Barba- 
dos, St. Lucia, and Martinique. 

Our shipboard orientation cruise 
terminated with our arrival back in 
Norfolk's 99° heat (the equator had 
been far cooler), but recollections of 
my experiences will long be with 
me. 

The opportunity to see the "real" 
Navy at work, to participate in some 
small way in a major U.S. diploma- 
tic mission, to see and enjoy new 
parts of the world, and to work in 
the Medical Corps of the opera- 
tional Navy was of great value and 
fascination to me. 

I shall never forget the novelty 
and thrill of a visit to a foreign port; 
the excitement of carrier flight op- 
erations; the beauty and tranquility 
of a sunset at sea. I truly hope that 
other scholarship students will avail 
themselves of this unique ACDU- 
TRA option and will thus be able to 
enjoy some of the experiences that 
so enthralled me. 



Volume 70, January 1979 



11 



Instructions & Directives 



Smoking in BUMED command activities 

The Surgeon General of the United States has determined that smoking is a hazard to health. 
The World Health Organization has suggested that the control of cigarette smoking could do 
more to improve health and prolong life in developed countries than any other single action in 
the field of preventive medicine. 

Today there can be no reasonable doubt that smoking is harmful — both to the smoker and to 
those who are exposed to the smoke. 

Policy. It is the policy of the Surgeon General of the Navy that Medical Department 
personnel, as health care professionals, should lead the way in encouraging programs and 
procedures that will decrease smoking. The following measures are designed to preserve the 
right of an individual to smoke as long as a reasonably contaminant-free environment can be 
maintained for nonsmokers. 

• Nonpatient care areas. Smoking shall be prohibited in elevators, shuttle vehicles, audi- 
toriums, conference rooms, and classrooms. Prompt action shall be taken to post No Smoking 
signs in these areas. Ashtrays shall be removed from auditoriums, conference rooms, and 
classrooms, and receptacles shall be placed just outside the doors so that individuals may 
dispose of cigarettes, etc., when they become aware of the smoking restriction. 

No-smoking areas will be established in eating facilities. 

Smoking may be permitted in private (nonpatient treatment) offices, staff lounges, and 
other specifically designated areas. 

In common work areas shared by smokers and nonsmokers, smoking shall be permitted only 
if ventilation is adequate to remove smoke from the work area and provide a healthful 
environment. Work space may be planned to accommodate the preferences of each group. 
provided that efficiency of work units will not be impaired and additional space or costly 
alterations will not be required. 

• Patient care areas. Since tobacco smoke itself is a health hazard, smoking shall be strictly 
controlled in patient care areas. 

Smoking by nonpatient personnel in patient care areas shall be prohibited. Navy health care 
personnel who smoke in front of their patients are derelict in their ethical duties to those 
patients. 

Ambulatory patients shall not be permitted to smoke in bed. They shall use smoking areas 
specifically designated for them. 

Patients confined to bed should be discouraged from smoking. 

Unsupervised smoking by patients classified as not mentally or physically responsible for 
their actions — including patients so affected by medications — shall be prohibited. 

Education. Emphasis should be placed on educational programs encouraging smokers not 
to adversely affect their own well-being and that of others. In particular, these programs 
should focus on high-risk personnel, such as those with chronic bronchitis, emphysema, 
asthma, and coronary heart disease, and upon special occupational groups, such as asbestos 
workers. Programs should include lectures, available films, pamphlets, and posters, and 
should be updated frequently with the latest available medical research information on 
smoking and health. 

Action. BUMED command activities shall ensure adherence to the measures set forth in 
"Policy" above. Commanding officers of medical treatment facilities shall further implement 
the policies stated in this instruction as necessary to ensure that smoking is controlled in a 
manner that best serves the interests of patient care treatment. — BUMED Instruction 6200. 10 
of 19 Sept 1978. 

Disaster control drills 

The JCAH Accreditation Manual for Hospitals requires that each hospital or medical center 
exercise its external disaster plan at least twice a year, and its internal disaster, fire, and 

12 U.S. Navy Medicine 



evacuation drills at least quarterly for each work shift (a minimum of 12 drills a year). BU- 
MEDINST 3440.7 requires that a semiannual report be made, documenting that the JCAH 
requirements have been met. 

Recent JCAH survey reports continue to cite hospitals and medical centers for not totally 
meeting JCAH requirements for conducting disaster drills. Also, the reporting requirements 
set forth in BUMEDINST 3440.7 have not been met by a number of hospitals and medical 
centers. 

BUMEDINST 3440.7 requires that semiannual reports be submitted to arrive at BUMED no 
later than 15 May and 15 November, covering the six-month period 1 November through 30 
April and 1 May through 31 October, respectively. Reports have arrived up to three months 
late and have covered periods other than those prescribed. Also, a number of hospitals and 
medical centers have failed to conduct the one external disaster drill and six internal drills re- 
quired during each six-month period. 

Naval medical facilities will ensure strict, continuous compliance with JCAH standards and 
BUMEDINST 3440.7 in conducting and reporting external and internal disaster control drills. 
Full documentation of these drills shall be maintained by each facility for review by JCAH 
survey teams; the Inspector General, Medical; and other authority. — BUMED Notice 3440 of 
28 Sept 1978. 

Aural rehabilitation 

NRMC Portsmouth, Va., and NRMC Oakland, Calif., are hereby designated as audiology and 
speech centers and as the principal treatment facilities for aural rehabilitation within the 
Medical Department. They shall provide a full range of professional services, including diag- 
nosis; prescription; issue, repair, and maintenance of hearing aids; a complete program of 
aural rehabilitation; and the preparation of medical boards when indicated. 

Other regional medical centers or naval hospitals that have the requisite staff and equip- 
ment may prescribe and issue hearing aids in those uncomplicated cases that do not require 
aural rehabilitation and are within the capabilities of the command. The terms "requisite 
staff" and "capabilities" shall be construed to include a fully trained or board-certified 
otolaryngologist, a fully trained audiologist, and audiometric equipment that is properly 
maintained and calibrated and capable of being used for recorded and live voice testing of 
speech reception and discrimination through both earphones and free field speakers, as well 
as pure tone testing facilities. 

Section IV of enclosure (2) to DOD Directive 1332.18 (enclosure (1) to reference (a)) states in 
part that when unaided hearing loss in the better ear is 30 decibels or more in the normal 
speech range (pure tone audiometric values in the 500, 1000, 2,000 cycles per second), the in- 
dividual will be evaluated at an audiology and speech center. Under these circumstances, all 
active-duty members whose primary diagnosis is hearing loss and whose fitness for continued 
duty becomes questionable shall be referred to the nearest naval hospital or medical center 
with the capabilities described above. 

Eligibility for hearing aids, as stated in BUMEDINST 6320.31 A, remains unchanged. Ser- 
vice provided to those eligible is expanded to include: 

• Issue of a second hearing aid to personnel being transferred overseas, or in critical as- 
signments. 

• Provision of replacement batteries, as required, by all naval medical treatment facilities. 

• Complete maintenance and repair services, to be provided through NRMC Portsmouth, 
Va., and NRMC Oakland, Calif. 

Hearing aids shall be procured through the Veterans Administration, except in an emer- 
gency or in unusual circumstances. Current item listings, price lists, and purchase procedures 
may be obtained from: VA Marketing Center (134J) (MC-3), P.O. Box 76, Hines, HI. 60141; 
telephone (312) 681-6795.— BUMED Instruction 6320.41B of 9 June 1978. 

Volume 70, January 1979 13 



The Move to Micrographics 



Why postpone the inevitable? 



LT Patrick A. Shannon, MSC, USN 



The national economy is under 
pressure, and it follows that we 
in medical administration are 
also. We are faced with the neces- 
sity of increasing our efficiency if 
we are to survive. It is a time for in- 
tensive activity to improve the ef- 
fectiveness of our operations (/). 

The bureaucracy of which we are 
all a part is engulfing us with count- 
less tons of paperwork, and the 
mountain of paper grows larger 
each year, despite our efforts to- 
ward "increased efficiency." 

As more and more people de- 
mand access to more and more in- 
formation, we must maintain data 
storage resources adequate to meet 
national security and legal require- 
ments. To further complicate the 
problem, the vast amount of paper- 
work generated by our society today 
is causing grave doubts about con- 



LT Shannon is the training officer. Naval 
Reserve Division, Bureau of Medicine and 
Surgery (Code 362). Washington. D.C. 
20372. Before arriving for duty at BUMED in 
June 1978, he was assistant chief. Patient 
Records and Tissue Repository Department. 
Armed Forces Institute of Pathology. Wash- 
ington, D.C. He was also the technical pro- 
gram manager for AFlP's Microform Docu- 
mentor Information Svstem. 



tinuing availability of natural re- 
sources (/). 

Kalthoff (2) described the situa- 
tion this way: 

We are, by any measure, a genera- 
tion of compulsive information magpies. 
File cabinets have spawned like rodents 
in spite of their heralded demise once 
the computer was to have become a 
force in our lives. We all understand the 
file folder. Very little is ever taken out of 
it. AH kinds of things, sensible and in- 
sensible, are added to it. Did you ever 
open a file and find three copies of the 
same item . . . again and again? That is 
totally human. When in doubt, add 
more. When the folder is not findable. 
start a new one. When the file drawer 
fills, start another. When the cabinet 
fills, another. When the office fills, start 
moving them into the hall, the closet, 
the cellar and ultimately into the ware- 
house. 

"Small wonder," he added, "that 
micromedia is gaining an increas- 
ingly sentinel role in the manage- 
ment of document based systems." 

Through the use of micrograph- 
ics we can combine the science, 
the art, and the technology by 
which much of our self-created di- 
lemma can be reduced to the 



medium of microforms, stored con- 
veniently and then easily retrieved 
for reference, 

The use of micrographics pro- 
motes efficiency, speed, and econ- 
omy. Microforms require only a few 
square feet of storage space to re- 
place the original documents that 
previously occupied a few thousand 
square feet. Further, they can be 
retrieved, displayed, and repro- 
duced in seconds, for just pennies a 
copy (3). 

But space-saving is not the only 
dividend. The seemingly insignifi- 
cant postage expense of a major 
medical center is, in reality, enor- 
mous; it increases annually and eats 
away at budgets. This expense can 
be reduced dramatically by the use 
of microforms. With microfilm, for 
example, we can airmail for 15 
cents, from coast to coast, the same 
information that would cost nearly 
$7 to mail in its original form. 

Moreover, the archival quality of 
microfilm can bring an end to the 



A microforms quality control technician 
checks a microfiche for resolution (clar- 
ity), density (image darkness), and gen- 
eral legibility before the original paper 
record is disposed of. 



14 



U.S. Navy Medicine 




Volume 70, January 1979 



15 




This single microfiche contains a 12-page medical record. It could accommodate up to 98 pages. 



age-old problem of dog-eared and 
frayed paper copies that are the rule 
in most medical records (.?). 

Still other major advantages of 
microforms are improved integrity 
of files, increased speed of service, 
and reduced labor. And each of 
these advantages can be translated 
into cost savings. 

An example of savings through 
file integrity can easily be seen in a 
situation where the activity of the 
file being used is considered to be 
heavy — as in the record office of a 
major medical facility. The im- 
proved integrity offered through 
micrographics will lower costs at- 
tributable to loss or misfiling of 
originals, and the resulting savings 
can justify any added costs the new 
system may incur over the old. The 
term "file integrity" in this in- 
stance refers not to security but, 
rather, to keeping the file in good 
order by never removing the master 
copy from the file room for tempo- 



rary lending. Any working copies 
that are needed can be reproduced 
in the file room in seconds, as a 
screen image, a duplicate micro- 
form, or an enlarged "back to 
paper" print (7). 

A typical situation in an outpa- 
tient record office might be this: 
The outpatient comes directly to the 
office, where he requests his record. 
The record (master microform) is 
pulled and copied, the duplicate is 
issued to the patient, and the 
master is placed in a suspense file. 
The patient then goes to his clinic, 
checks in for his appointment, and 
is seen by a practitioner. By in- 
serting the microfiche* in a viewer, 



*A microfiche is a single sheet of microfilm 
containing multiple microimages (98 images 
at a reduction ratio of 24; 1) in a grid pattern. 
These are updatable and erasable in the 
present state of the art. This microform ap- 
pears to be the natural choice for individual 
medical records. 



the practitioner can review the pa- 
tient's entire record — up to 98 
pages on one 4" X 6" fiche — to up- 
date himself on the patient's situa- 
tion. He then records on a standard 
form any medication or other treat- 
ment he prescribes for the patient. 

After the patient leaves, the 
microfiche and the standard form 
are returned to the record office, 
where (1) the fiche is destroyed, (2) 
the standard form is added to the 
master microform to update it, (3) 
the standard form is destroyed, and 
(4) the master is returned to the 
active files. Any laboratory tests, 
consultation reports, X-ray reports, 
and the like that are received by the 
record office at a later date would be 
added to the master microfiche in 
the same manner. 

There are, of course, several 
possible variations to the routine 
just described — e.g., delivering the 
microfiche copy to the appropriate 
clinic the night before the patient's 



16 



U.S. Navy Medicine 



appointment, thus eliminating most 
of the initial record retrieval the pa- 
tient must go through. 

Costigan (/) writes: "It is easy to 
see how this will, in turn, increase 
the speed of service by minimizing 
the waiting time that might other- 
wise have resulted from a docu- 
ment's being temporarily out-of-file 
or its having been transferred to 
less accessible storage. 

"Micrographics saves labor in 
several ways," he adds, "but two 
factors predominate: (1) the reduc- 
tion in sheer bulk afforded by mini- 
aturization of records, and thus a 
reduction in search and handling 
effort, and (2) the relative ease with 
which micrographic systems lend 
themselves to automation." 

Microfiche file systems that are 
completely random are now avail- 
able. These use coded jackets for 
the microfilm and enable the system 
operator to pull and file records 
completely at random, simply by 
using a numbered keyboard. Such a 
system could enable an outpatient 
record office to cut its manpower 
requirements drastically. 

The entire process of record 
search, retrieval, and return to file 
is done automatically at a keyboard, 





This wet-process copier will duplicate a microfiche in seconds, for just pennies a 
copy. 



With this reader-printer, the operator 
can view a microform and produce a 
"back to paper" copy. 



through the use of the patient's ac- 
cession number (Social Security 
number). After the number is en- 
tered in the system, the proper 
microfiche is automatically ejected 
in seconds. The record is then 
copied, the copy issued, and the 
master returned to file automatical- 
ly and completely at random — again 
in just seconds. Granted, the system 
is expensive, but for a large opera- 
tion it is a cost-saving one. 

Cost-effectiveness studies could 
be utilized to justify this kind of 
system for smaller activities; other- 
wise, a standard manual filing 
system should be used. In consider- 
ing the cost effectiveness of a sys- 
tem, we must not forget that speed 
of service and the other major ad- 
vantages of using microforms will 
be inherent in it also. 

Microforms can also be used for 
miniaturization of X-ray films. 
(The U.S. Army is currently 
evaluating X-ray miniaturization at 
Eisenhower Medical Center, Fort 
Gordon, Ga.) In August 1976, I con- 
ducted an informal survey relating 
to this possibility, through a ques- 



tionnaire sent to major and some 
minor naval medical facilities, both 
afloat and ashore. I based my ques- 
tions on knowledge I had acquired 
while attending a course in micro- 
graphics at the 3M Technical Train- 
ing Center, St. Paul, Minn., and on 
discussions with the Radiology De- 
partment at the Armed Forces In- 
stitute of Pathology (AFIP). 

Twenty-two responses were re- 
ceived from the major naval medical 
facilities. Individuals responding to 
the survey ranged from those with 
titles unknown to chiefs of radiol- 
ogy. Annual numbers of films proc- 
essed ranged from 800 to 968,000. 
Films on file at the various facilities 
ranged in number from .012 million 
to 5.5 million, with one facility re- 
porting the number "unknown." 

Asked whether their facilities 
were involved in the silver recovery 
program, three respondents replied 
no and all others reported yes. 
Twelve of the radiology services re- 
ported that they did not need the 
extra space miniaturization could 
provide; nine said they could use 
the space; one did not answer the 
question. Not surprisingly, some 



Volume 70, January 1979 



17 



facilities said they neither wanted 
nor needed automation or miniaturi- 
zation. 

Because of the informal nature of 
the survey, its value is not only 
limited but questionable. However, 
surveys of this type can provide in- 
teresting and valuable insights if 
interpreted for what they really are. 
Random polls and "off the cuff" 
surveys are the yardsticks that pro- 
fessional pollsters use most often. 

In discussions with the AFIP 
radiologists, it was determined that 
the smallest roentgenogram they 
would accept would be the 105 mm. 
This is the same size as a standard 
microfiche film (4" X 6"). 

Systems are available that will 
copy a 14" X 17" X-ray film and re- 
duce it to a very handy 35-mm regu- 
lar photographic slide in less than 
10 seconds — this, according to the 
manufacturer, without any loss of 
resolution. (Resolution is the ability 
of optical systems and photographic 
materials to make fine details of an 
object visible.) But the AFIP radiol- 
ogists felt that a 35-mm slide would 
be "too small" and "too easy to 
lose." Their main fear, however, 
was that there would always be a 
doubt as to whether everything that 
was on the original film would also 
appear on the miniaturized copy or 
a subsequent enlargement — and, 
indeed, as to whether artifacts 
(lines, marks, etc.) might be added 
somewhere along the line. 

Keeping in mind that all these 
opinions are valid to the individual, 
one must also remember that the 
mass chest X-ray programs of the 
past, both public health and mili- 
tary, were carried out by radiolo- 
gists reading a roll of developed 80- 
mm film with a high degree of relia- 
bility and success. Moreover, some 
large civilian institutions, such as 
Holy Cross Hospital in Metropolitan 
Washington, D.C., are currently 
solving their X-ray film storage 
problems through the use of minia- 
turized films, which attests to a cer- 
tain degree of user confidence. 

In any case, the reduction of a 
standard-size X-ray film (14" X 
17") to a more manageable pocket 




Each of these commonly used rotary files— 10' X 8' X 4'— can hold up to 200,000 
medical records or X-ray films on 4" X 6" microforms. 



size of 4" X 6" (105 mm) would not 
only save considerable space but 
would also allow duplicates of roent- 
genograms to be filed in the pa- 
tient's medical record. 

The X-ray film would conceivably 
be miniaturized after the radiologist 
had made his initial report on the 
full-size roentgenogram. The minia- 
ture would be used for storage, both 
active and archival, and would still 
be completely readable. An added 
advantage of this system is that 
while we would be saving money in 
the storage, handling, mailing, etc., 
of miniatures, the silver reclaimed 
from the standard-size X-ray films 
could help offset the initial outlay 
for miniaturization. 

One thousand 14" X 17" X-ray 
films contain 35 troy ounces of sil- 
ver. During processing, 27 ounces 
are transferred to the fixative and 7 
ounces remain on the film (4). (The 
remaining ounce is lost among the 
developer, the wash, and the fixa- 
tive.) If we use as an example a 
radiology service of a large naval 
regional medical center that would 
process some 300,000 films per year 



— and that would have some three 
quarters of a million films on active 
file and an equal number in archival 
storage — it should be clear that a 
good deal of money could be saved 
through silver reclamation. The 
NRMC in question should produce 
about 10,500 troy ounces of silver 
reclaimed from X-ray films in its 
active and archival files. Because 
the price of precious metals is con- 
stantly fluctuating, I shall not 
attempt to arrive at a monetary 
figure for that amount of silver, but 
it would be sizable. 

Thus far, I have touched on just 
two possible uses of micro- 
forms in medical facilities. 
They could also be used for: 

• in-patient records; 

• archival storage; 

• prescription files for the phar- 
macy (coded roll microfilm is best 
here), with automatic search capa- 
bility; 

• financial and materiel-manage- 
ment records; 

• personnel records. (The Army 
is now microfilming personnel rec- 



18 



U.S. Navy Medicine 



ords in its RAM II project (5), an 
updatable system that is front- 
ended by a minicomputer and has 
random file and retrieval capabili- 
ties. The Navy is also converting its 
personnel records to microforms.) 

The list of potential uses could go 
on and on, and is limited only by 
one's imagination. 

The Armed Forces Institute of 
Pathology currently has a $1.8 mil- 
lion contract with a civilian vendor 
to transfer to microfiche some 1.3 
million accessioned cases — one of 
the largest microfilm efforts ever 
attempted. When the current two- 
year contract expires, the AFIP will 
either microfilm records (which 
average 10 pages each) as they are 
accessioned from contributors 
(about 200 per day) or contract the 
work out on a yearly basis. 

Unless competent micrographics 
personnel are readily available, any 
facility considering the move to 
microfilm should do so only under 
contract; an in-house effort without 
expertise will surely result in dis- 
aster. 

New facilities should begin minia- 



) 




To use this reader-printer with automa- 
tic search capability, the operator keys 
in an identifying number (e.g., patient 
accession number, prescription num- 
ber, etc.). The machine selects the ap- 
propriate record from a microfilm roll. 
(Each film cartridge holds up to 6,000 
pages.) 



i 




Called "ultrafiche," this 5-sq-mm microform contains both the Old and the New 
Testaments and must be read with a 100X microscope. Impractical for normal use, 
it's nevertheless an excellent example of Industry capability. 



turization as soon as they open for 
business. Needless to say, highly 
trained and qualified personnel 
should be consulted before such a 
program is established, since 
chances of program disaster and 
financial loss are greatly increased 
without such consultation. 

Along these same lines, if indi- 
vidual efforts are made to microfilm 
records, qualified trained personnel 
should be utilized on board to en- 
sure that proper quality control is 
established and maintained, lest the 
film become unreadable with age. 
Obviously, this could have far- 
reaching legal and storage implica- 
tions. 

Military Specification MIL-M- 
38748A of 1 Dec 1970 outlines the 
specifications for microfiche and 
should be adhered to rigidly. 
Other MIL-specs in print cover lot- 
sampling sizes and other pertinent 
data needed to ensure that micro- 
film will meet federal archival 
standards and that the facility is 
getting what it pays for. 

Finally, many publications, much 
information, and expert assistance 
are available from the National 
Micrographics Association, 8728 
Colesville Rd., Silver Spring, Md. 
20910. 

To summarize, there are no 
obstacles that cannot be or have not 
already been overcome in relation to 
microfilming of medical records. 

The microform is an idea whose 
time has come. It is inevitable. 

Why not begin now? 

References 

1. Costigan DM: Micrographic Systems. 
Silver Spring. Md.: National Micrographics 
Association, 1975, p 25. 

2. Kalthoff RJ: Document vs. data based 
information systems. J Micrographics 10:81. 
1976. 

3. Avedon DM: Introduction to Micro- 
graphics. Silver Spring, Md: National Micro- 
graphics Association, 1973, p 2. 

4. Recovery of silver from expended 
photographic material. U.S. Air Force Tech- 
nical Manual, T.O. 10-1-25, Change 1 of 1 
May 1969, p 2-2. 

5. Proposed Microform System for Ad- 
ministration of HQDA Military Personnel 
Records. Report No. 75-03. Department of 
the Army, RAM II Task Force, Office of the 
Adjutant General, April 1975. 



Volume 70, January 1979 



19 



ACHA Admits New MSC Members 



Forty-one Navy Medical Service 
Corps officers have been accepted 
to nomineeship in the American 
College of Hospital Administrators 
(ACHA), and three have been ad- 
vanced to membership in that 
Chicago-based professional society. 
Their admission took place at 
ACHA's recent 44th Annual Meet- 
ing, held concurrently with the 
Annual Meeting of the American 
Hospital Association. 

In their new affiliation, these offi- 
cers join a persona] membership 
organization composed of more than 
14,000 leading chief executive offi- 
cers and their administrative col- 
leagues, serving hospitals and 
health service facilities in the 
United States, Canada, and other 
countries. 

The ACHA was founded in 1933 
to assure high standards of compe- 
tency in hospital and health service 
management. To do so, it conducts 
a comprehensive educational pro- 
gram directed toward improvement 
of all facets of administration. In 
addition, it publishes the major pro- 
fessional journal serving the broad 
health service field — Hospital and 
Health Services Administration — 
and regularly issues monographs on 
challenging issues relating to health 
care delivery. 

Membership in ACHA is divided 
into three categories: nominee, 
member, and fellow. To advance in 
status, affiliates must qualify by 
passing stringent written and oral 
examinations. 

MSC officers newly advanced to 
membership are: 

LCDR Marshall S. Duny, MSC, USN 
LCDR Everette L. Wilson, MSC, USN 
LT David G. Daniel, MSC, USN 

MSC officers newly admitted to 
nomineeship are: 

CAPT Leslie J. Schaffner, MSC. USN 
CDR E.R. Christian, MSC, USN 
CDR Donald R. Craig. MSC. USN 



CDR Frank D.R. Fisher, MSC. USN 
CDR Raymond B. Kessler, MSC, USN 
LCDR Wendell L. Chappell, MSC, USN 
LCDR John P. Kelly, MSC, USN 
LCDR James D. Knight, MSC, USN 
LCDR Sergei F. Pron, MSC, USN 
LCDR Edward A. Rice, Jr., MSC, USN 
LCDR Todd R. Stemple, MSC, USN 
LT Phillip J. Barnett. MSC, USN 
LT Earl Bearty, MSC. USN 
LT William H. Brent, MSC, USN 
LT John R. Buffington, MSC. USN 
LT Thomas Candelaria, MSC, USN 
LT Mark E. Celmer, MSC, USNR 
LT William H.G. Craig, MSC, USN 
LT Herald C. Edmond, Jr., MSC, USNR 
LT Frederick W. Ewing, MSC, USN 
LT Carmelo F. Fermin, MSC, USNR 
LT Harrison T. Ferris, MSC, USNR 
LT Louis 0. Garcia, MSC, USNR 
LT William R. Gilchrist, MSC. USNR 
LT John R. Hetrick, MSC, USN 
LT William C. Johnson, MSC, USNR 
LT David H. Lardy, MSC, USNR 
LT Daniel R. Longo, MSC, USNR 
LT Michael E. Plante, MSC, USNR 
LT Randolph A. Redpath, MSC, USNR 
LT Bernard Shapiro, MSC, USNR 
LT Gary L. Stokes, MSC, USNR 
LT Lee W. Tompkins, MSC. USN 
LT Lawrence J. Walters, MSC, USN 



LT Joseph A. Wassell, MSC, USNR 
LTJG Robert G. Chandler, MSC, USNR 
LTJG John F. Clark, Jr., MSC, USNR 
LTJG Jeffrey P. Harrison, MSC. USNR 
LTJG Tod N. Lambert, MSC. USNR 
LTJG Dale M. Nachreiner, MSC, USNR 
LTJG Thomas E. Payne, MSC, USNR 

Other Navy affiliates of ACHA 
are: 

Nominees 

CAPT Francis G. Anderson, Jr., MSC, USN 
CAPT Lewis E. Angelo, MSC, USN 
CAPT Robert C. Elliott, MC, USN 
CAPT Roy W. Tandy. MSC, USN 
CDR Lawrence L. Biesiadny. MSC. USN 
CDR Frederick F. Briand, MSC, USN 
CDR Richard L. Devault, MSC, USN 
CDR Walter A. Godfrey, MSC, USN 
CDR Arthur D. Hatten. Jr., MSC, USN 
CDR Jack E. Johns, MSC, USN 
CDR Bobby L. Stephens, MSC, USN 
CDR Thomas E. Thomas, MSC, USN 
LCDR David E. Anderson, MSC, USN 
LCDR Robert S. Kavler. MSC, USN 
LCDR William J. Lambert, MSC, USN 
LCDR Larry G. Lobaugh, MSC, USN 
LCDR Michael L. Mitchell. MSC, USN 
LCDR Leonard L. Moore, MSC, USN 
LCDR William P. McGrath, MSC, USN 



A NOTE FROM THE MSC CHIEF 

The highest sense of professionalism is absolutely essential within 
the Medical Service Corps, as in all communities of the Navy Medical 
Department. Formal training and education, the requirements in 
many professional fields for certification or licensure, a code of 
ethics, and a special attitude by which to govern one's practice are all 
a part of being a professional . 

So too, of course, are affiliation and active participation in the af- 
fairs of professional societies appropriate to one's field. Often in the 
military, officers neglect those societies, members of which are pre- 
dominantly civilian professionals. This should not be. It is vita! that 
we of the Armed Forces remain abreast of our professional colleagues 
in civil life, in part so that we may better serve the military and in part 
because we have something to offer them, as well. 

The accompanying article, prepared by CAPT Victor Swindall 
(MSC) and CDR Charles Loar (MSC). acknowledges the importance 
of professional activity among those officers of the Medical Service 
Corps affiliated with the American College of Hospital Administra- 
tors. My personal congratulations go to all officers recently admitted 
to nomineeship or promoted to membership status, as to those previ- 
ously so honored. 

—CAPT Paul D. Nelson, MSC, USN 



20 



U.S. Navy Medicine 



LCDR Reginald E. Newman, MSC. USN 
LCDR Salvatore J. Profita, MSC, USN 
LCDR Vernon P. Sandal, MSC. USN 
LCDR James P. Smith, MSC, USN 
LT Robert R. Ayers, MSC, USN 
LT J. Thomas Benson, MSC, USN 
LT Harry C. Coffee, MSC, USN 
LT Kenneth D. Gibson, MSC, USN 
LT Charles W. Hagen, MSC, USN 
LT Russell D. Harbaugh, MSC, USN 
LT Dean A. Herman, MSC, USN 
LT Carl J. Hooton, MSC, USN 
LT Jeffrey A. Kramer, MSC, USN 
LT Carl C. Langston, Jr., MSC, USN 
LT Patrick L. Mahin, MSC, USN 
LT Edwin L. Makamson, MSC, USN 
LT Joseph E. McBride, MSC, USN 
LT Jimmy R. McCormick, MSC, USN 



LT Kenneth R. Randle, MSC, USN 

LT Thaddeus H. Sparkman, MSC, USN 

LT John W. Stine, MSC, USN 

LT Gary J. Spinks. MSC, USN 

LT Frederick R. Tittman, MSC, USN 

LTJG Marc V. Weiner, MSC. USN 

Members 

CAPT Eugene M, Bryant. MSC, USN 
CAPT Hubert H. Sowers, MSC, USN 
CAPT Victor A. Swindall, MSC, USN 
CDR Robert K. Zentmyer, MSC, USN 
LCDR William M. Buckley, MSC, USN 
LCDR John B. Farnham, MSC, USN 
LCDR David H. Fisher, MSC, USN 
LCDR William L. Roach, MSC, USN 
LCDR Douglas Shepherd, MSC, USN 
LT Robert E. Elster, MSC, USN 



Fellow 

CDR Charles R. Loar. MSC, USN 

Information regarding ACHA ad- 
mission requirements may be ob- 
tained from the Director of Mem- 
bership, American College of Hos- 
pital Administrators, 840 N. Lake 
Shore Dr., Chicago, 111. 60611, 
Questions related to college partici- 
pation may be directed to the Office 
of the Chief, Medical Service Corps, 
Bureau of Medicine and Surgery 
(Code 71), Department of the Navy, 
Washington, D.C. 20372. 



Letters 



We were pleased to see, in the 
September 1978 issue of U.S. Navy 
Medicine, the article in the Schol- 
ar's Scuttlebutt section on "The 
Medical School Liaison Officer." 

This article, identifies for Navy 
scholars their ombudsman on the 
local scene, and recognizes the fine 
work of the men who perform these 
duties — entirely, we might add, 
without pay. 

Unfortunately, the list you print- 
ed does not represent the officers 
who were serving as MSLO at your 
press time, but only a partial list, 
with many inaccuracies . . . [S]ever- 
al outstanding officers who have 
been working as MSLO for years 
aren't even listed. 

For that reason I would appreci- 
ate it if you would print this letter 
and indicate that the following are 
also Medical School Liaison Officers 
— those with the asterisk, for a long, 
long time. 



Tufts: CAPT Eugene Laforet, MC, USNR 
(Ret.)*; CAPT Oscar Donnefeld, MC, 
USNR-R 

State University of New York (Stoneybrook): 
CAPT Stanley Wallach, MC, USNR-R; CAPT 
W.W. Shreeve, MC, USNR-R 



Temple: CDR Alfred A. Bove, MC, USNR-R 

Ohio State: CAPT Donald A. Senhauser. 
MC, USNR-R 

Georgetown: CAPT John F. Kurtzke, MC, 
USNR-R 

Howard: CDR Louis Ivey, MC, USNR-R 

Eastern Virginia Medical School: CAPT 
Robert Brownson, MSC, USNR-R 

University of Virginia (Charlottesville): 
CAPT John A. Owen, MC, USNR-R; CAPT 
Robert W. Cantrell, MC, USNR-R 

Medical College of Georgia: CDR William T. 
Freeman, MC, USNR-R 

Emory: CDR Kenneth A. Scheldt, MC, 
USNR-R 

University of Miami: CDR Donald (not 
Ronald) J. Hagan, MC, USNR-R* 

University of Tennessee: CAPT Robert L. 
Summitt, MC, USNR-R*; CAPT Daniel J. 
Scott; CAPT Ernest L. Cashion, MC, 
USNR-R 

University of Mississippi; CDR Gordon D. 
Deraps, MC, USNR-R 

Louisiana State (New Orleans): RADM 
Winston H. Weese. MC, USNR-R* 

University of Texas (Dallas): CDR Carl E. 
Renfro, MC, USNR-R 



State University of New York (Syracuse): University of Chicago: CDR Morris D. 
CAPT Richard J. Blair. MC, USNR-R Kerstein. MC, USNR-R 



University of Wisconsin: CAPT George 
Kroncke, MC. USNR S2 

University of Missouri (Columbia): CAPT 
Robert L, Blass, MC, USNR-R; CDR Carl G. 
Kardinal, MC, USNR-R 

University of Missouri (Kansas City): CDR 
Robert B~. McFarland, MC, USNR-R 

St. Louis University: CDR Hendrik B, 
Earner, MC, USNR-R* 

University of Nebraska: CDR Alvin M. Earle, 
MSC, USNR-R 

University of Arizona: CAPT Edward D. 
Waldmann, MC, USNR-R; LCDR Gary T. 
Tizard, MC, USNR-R 

University of Utah: CDR Richard E. Kanner, 
MC, USNR SI 

University of Nevada (and College of Osteo- 
pathic Medicine of the Pacific): CAPT Harry 
S. Hooper. USNR (Ret.)* 

Philadelphia College of Osteopathic Medi- 
cine: LCDR Ronald A. Kirschner, MC, 
USNR-R 

M.H. Backer, Jr., RADM. MC. USNR 

Director. Medical School Liaison 

Officer Program 

We regret very much indeed that 
the information contained in this 
article was so outdated and we 
apologize to those Medical School 
Liaison Officers who were inadvert- 
ently omitted from our list. — Ed. 



Volume 70, January 1979 



21 



IMAVMED Newsmakers 



At 13, an age when many girls are 
fascinated by horses, Maria Patter- 
son was captivated by aerial steeds. 
John Glenn had just become the 
first American to orbit the earth, 
she recalls, and "airplanes were ex- 
citing" — the next best thing to a 
space capsule. 

Now a member of the Navy Nurse 
Corps, LT Patterson serves as an in- 
structor at Hospital Corps School, 
Great Lakes, 111. Off duty, she's also 
a teacher. As a certified flight in- 
structor for single- and multi-engine 
aircraft and instrument flying, she 
introduces aspiring pilots to the in- 
tricacies of the world of flight. 

A 15-year member of the Civil Air 
Patrol, LT Patterson used her last 
summer's leave to escort CAP 
cadets to Sweden, under the organi- 
zation's International Air Cadet Ex- 
change. 




LT Patterson: a 'second career' 





1 , -i 



Reenlistees: 36 more years 

22 



CAPT Bynum: scoring a 'first' 



Flying is a "fascinating second 
career," says LT Patterson. In her 
off-duty hours, you're not likely to 
find her with feet on the ground. 

In a recent ceremony at U.S. Naval 
Regional Medical Center Japan, 
CDR Joan C. Bynum, assistant 
director of nursing service, became 
the first black woman in the 203- 
year history of the Navy to attain the 
rank of captain. Her silver-eagle 
collar device was pinned on by 
CAPT B.L. Johnson, the medical 
center's commanding officer, who 
recalled that in June 1957 he and 
CAPT Bynum had shared another 
memorable occasion: their gradua- 
tion from Meharry Medical College, 
when he received his degree in 
medicine and she was awarded a 
bachelor's degree in nursing. 

At Naval Regional Medical Clinic 
New Orleans, La., eight petty offi- 
cers — 10% of the clinic's enlisted 
staff — have demonstrated their 
pride in naval service in the most 
foreful way possible: by reenlisting 
en masse, for a collective obligation 
of 38 more years. The reenlistees 
are: HM1 Joseph W. Adams, Jr.; 
HM1 Tommy R. Carver; IC1 John 
0. Gregory; HM1 Darlene E. Ptke; 
HM2 Ronald E. Dove; HM2 Daniel 
J. Walker; HM2 Donna V. Wil- 
liams; and HM3 Rex A. Reade. 

U.S. Navy Medicine 



First Regional Medical Record 

Meeting Held 



yj o improve communication 
among naval medical record person- 
nel, the Bureau of Medicine and 
Surgery recently sponsored a two- 
day regional meeting of representa- 
tives from 11 naval hospitals in the 
eastern half of the country. 

Background. Medical audit and 
utilization review have become a 
way of life at naval medical treat- 
ment facilities. Efficient implemen- 
tation of these processes requires 
not only that the medical record be 
complete, but that the diagnostic 
and surgical codes — the keys to de- 
cision-making — accurately reflect 
the condition(s) for which the pa- 
tient was treated. 

At present, guidelines for coding 
medical diagnoses and surgical 
operations are contained in ICDA-8 
(.International Classification of Dis- 
eases, Adapted for Use in the 
United States) and in BUMEDINST 
6300.3, Inpatient Data System. 

At the Naval Medical Data Ser- 
vices Center (NMDSC), information 
from the field is subjected to a 
computer edit to eliminate impossi- 
ble diagnoses — e.g., a female diag- 
nosis for a male patient. In addition, 
the NMDSC medical record admin- 
istrator has day-to-day contact with 
coding personnel in the various 
naval facilities. These contacts indi- 
cate, however, that there is some 
variation in interpretation of guide- 
lines, and that not enough is being 
done in the area of cross-fertiliza- 
tion of ideas to improve accuracy 
and uniformity of diagnostic coding. 

To attack these problems, 
NMDSC last spring recommended 
to the Surgeon General three 
courses of action: (1) organization of 



regional meetings for medical 
record personnel; (2) issuance of a 
newletter covering effective medical 
record procedures, solutions to 
complex coding problems, and new 
developments in the field; and (3) 
inclusion of medical record infor- 
mation in training courses for pa- 
tient-affairs personnel. 

These proposals have been ap- 
proved by the Surgeon General, 
Thus far, informal coding memo- 
randa have been circulated to medi- 
cal record administrators in naval 
hospitals, and the first regional 
meeting was held 21-22 Sept 1978 in 
Bethesda, Md. 

Meeting. The program — planned 
by Mrs. Muriel Brandford, RRA, of 
NMDSC — comprised presentations 
by representatives of NMDSC, the 
Bureau of Medicine and Surgery, 
the Naval School of Health Sciences, 
and the Veterans Administration; 
by medical record administrators 
from two large naval hospitals; and 
by the president of the Medical 
Record Association of the District of 
Columbia. Topics ranged from cod- 
ing problems in the field to an in- 
troduction to ICD-9, neweist version 
of the International Classification of 
Diseases. 

Conclusions reached by meeting 
participants included the following: 

• Hospitals should share medical 
audit criteria. BUMED should make 
available audit criteria to hospitals 
when requested. 

• By means of a newsletter and 
future meetings, hospitals should 
share methods and procedures used 
in processing medical records. 

• Better communication is 
needed between medical record 



personnel and physicians filling out 
medical records. For example, when 
a physician records many diag- 
noses, is the first diagnosis men- 
tioned the principal diagnosis for 
which the patient was treated? 

• Physicians should be encour- 
aged to record diagnoses rather 
than symptoms whenever possible. 

• The complete medical record 
should be made available to medical 
record coders to improve the ac- 
curacy and completeness of data re- 
ported to NMDSC. 

• The use of Hospital Corps per- 
sonnel to code medical records is 
acceptable only if they are given 
training in performing this function 
and if they are to be assigned to this 
task for an extended period of time. 

• NMDSC should make available 
to each hospital computer printouts 
showing length of stay, by diagno- 
sis, for its patients and for patients 
in other hospitals with comparable 
bed size and mission. 

Future programs. A question- 
naire completed by participants at 
the meeting's conclusion indicated 
they felt such gatherings are very 
useful in communicating ideas and 
should be continued. Participants 
stated that future programs should 
devote more time to discussion of 
variation among hospitals in meth- 
ods used to process medical rec- 
ords. But they singled out complex 
coding problems as the topic in 
most need of extensive discussion. 

Plans for future meetings will 
depend on availability of funds. All 
participants expressed special in- 
terest in the presentation made by 
CAPT J.J. Quinn <MC), which fol- 
lows this report. 



Volume 70, January 1979 



23 



This conference is indicative of the Navy's increased interest in 
use of medical records as one of the means of evaluating deliv- 
ery of medical care.' 



Diagnostic Data.' A Key to Decision-Makin ( 



CAPT J.J. Quinn, MC, USN 



This is the first conference on medical records that 
the Bureau of Medicine and Surgery has spon- 
sored, and it is indicative of the Navy's increased 
interest in use of medical records as one of the means of 
evaluating the delivery of medical care. Our Surgeon 
General, VADM Arentzen, is deeply interested in this 
conference — he was the one who approved it — and 
hopes that it will be a trailblazer for future get-togeth- 
ers that will ensure continuing progress in the area of 
medical record management. 

When we talk about a medical record, we are not 
merely referring to a sheaf of papers arranged in a 
folder and placed in a file. We are also referring to 
everyone who has an input into this record — doctors, 
nurses, laboratory personnel and, last but not least, 
medical record personnel. You are the last group to see 
the medical record, and you bear a heavy responsibility 
for seeing that the standards of accreditation with 
respect to medical records are met. 

The manual of the Joint Commission on the Accredi- 
tation of Hospitals states: "A hospital shall maintain 
medical records that are documented accurately and in 
a timely manner, that are readily accessible, and that 
permit prompt retrieval of information including statis- 
tical data." 



CAPT Quinn is Deputy Director of Program Planning and Analysis 
at the Bureau of Medicine and Surgery, Washington, D.C. 20372. 
This paper was presented at the Regional Medical Record Meeting, 
held 21-22 Sept 1978 at the Naval Medical Research Institute, Na- 
tional Naval Medical Center, Bethesda, Md. 



How do you accomplish this? In the same accredita- 
tion manual, there is a description of the role of medical 
record personnel in the hospital. As you are well aware, 
this role includes a variety of duties that not enough 
people realize are necessary. These duties involve 
supervision of data gathering, training of clerical per- 
sonnel, screening medical records for completeness 
and compliance with established criteria, helping to 
design forms, suggesting to doctors and nurses how 
they can improve their entries in the medical records, 
assisting in medical staff review, and ensuring protec- 
tion of the privacy of patients and physicians whose 
records are involved in quality-of-care activities. 

So we see that the medical record administrators are 
required to be in touch with all professional services in 
the delivery of medical care. Medical record adminis- 
trators also communicate — although indirectly — with 
Bureau of Medicine and Surgery program managers 
and with the special studies, such as medical audits, of 
which they are an integral part. 



In general, medical coding is a means of communi- 
cation. To the extent that the coding is accurate and 
complete, one can receive a meaningful message. 
We all know that the key to the medical record is the 
file number. The reason for selecting a record with a 
given file number is that the patient has some charac- 
teristic that is of interest, and this characteristic is 
summarized in a code. Thus, in the case of medical 



24 



U.S. Navy Medicine 



audits, the diagnostic or surgical code is the first crite- 
rion we use in the selection of our cases, and the repre- 
sentativeness of the conclusions to be drawn depends 
primarily on these codes — assuming, of course, that the 
File numbers are correct. 

For example, if we wish to conduct a medical audit 
for cases with myocardial infarction, we go to the diag- 
nostic index and select those folders identified as listing 
myocardial infarction among the diagnoses on the cover 
sheet. If among those records pulled, we find an error 
in coding, we can always delete that case from the 
study. But what are we missing by not including that 
case that has been miscoded? 

The miscoding has other ramifications. If the crite- 
rion for selection of a diagnosis for study is the number 
of cases, a systematic error in coding could result in 
erroneous selection or omission of a given condition. 

I always wondered how accurate the coding of medi- 
cal records was, and a report issued by the National 
Academy of Sciences in 1977 — "The Reliability of 
Hospital Discharge Abstracts" — gave me an answer 
that really surprised me. This study, involving many 
hospitals, disclosed that the code for the principal 
diagnosis was correct in only 65% of the cases ex- 
amined, and that the code for the principal procedure 
was correct in 73 % . Not all the errors were due to cod- 
ing. But in the case of the principal diagnosis almost 
half the errors were due to coding, and in the case of 
surgical operations two thirds of the errors were due to 
coding. Most of these errors were occasioned by routine 
and systematic misuse or misunderstanding of the cod- 
ing system — e.g., using the alphabetical index but not 
the tabular listing and not reading inclusions. 

I hope that the error rate in our naval hospitals is no- 
where near as high as that in the Academy study, be- 
cause we are using the diagnostic and surgical data for 
decision- making. At present in the Bureau we have a 
Quality Assurance Committee that tries to evaluate the 
quality of care given to patients in naval medical treat- 
ment facilities. It occurs to me that there should be a 
Quality Assurance Committee among medical record 
personnel to look into the area of quality coding. 



Let me describe briefly some of the problems we are 
faced with in the Bureau, and some of the ways we 
use diagnostic and surgical data in our day-to-day 
decision-making. 

As you know, we have, in the past two years, insti- 
tuted medical holding companies. To determine 
whether the holding company is being used as in- 
tended, we have been reviewing the diagnoses of indi- 



viduals sent to holding companies. Some of this infor- 
mation comes from dispatches for patients in the hold- 
ing company 60 days or more, but much of the informa- 
tion comes from the computer that contains the diag- 
nostic and surgical codes for these individuals. 

We also need diagnostic and surgical data to help us 
estimate the number of physicians in various specialties 
who are needed in different hospitals. In a recent in- 
stance, we were looking into the number of neurosurgi- 
cal operations, and the data we received from the Medi- 
cal Data Services Center was very useful in helping us 
make decisions on the number of neurosurgeons 
needed in our hospital system. 

Length of stay in naval hospitals is another area of 
great interest. The Office of Management and Budget 
and the General Accounting Office also make much use 
of this data. For your information, they are comparing 
length of stay in our naval hospitals with that in civilian 
hospitals. Thus you can see that it is most important for 
diagnoses to be coded correctly, so that we are able to 
compare like things. 



'. . . you bear a heavy respon- 
sibility for seeing that the 
standards of accreditation with 
respect to medical records are 
met.' 



In this connection, the necessary data for correct 
classification are most important. In making length-of- 
stay comparisons, cases are classified into four cate- 
gories: single diagnosis without surgery; single 
diagnosis with surgery; multiple diagnoses without 
surgery; multiple diagnoses with surgery. The length of 
stay for complicated cases — those with more than one 
diagnosis — is higher than that for uncomplicated cases: 
those with one diagnosis. In addition, any case with 
surgery for a specific diagnosis remains for a longer 
period in a hospital than those without surgery. So you 
can see that if cases are incompletely coded, compari- 
sons with civilian facilities will put the Navy at a disad- 
vantage. 

You may also be interested to know that each month 
the Surgeon General pays very close attention to the 



Volume 70, January 1979 



length of stay of patients in each of our hospitals, and 
he is most persistent in seeing that excessive lengths of 
stay are reduced. As you know, the total length of stay 
in any hospital, for each type of beneficiary, depends on 
the diagnostic mix. Thus, for your individual hospital, if 
the cases are not classified correctly, the length of stay 
in most instances will appear higher than one would 
ordinarily expect. 

This type of classification also is important in plan- 
ning for a new hospital. After we know the population 
to be served, we must estimate the number of patients 
who will be admitted with various diagnoses, and we 
must estimate how many of these patients will have 
surgery. This is important not only in planning for hos- 
pitals, to see how many operating rooms might be re- 
quired, but also in determining the needed types of 
medical specialists. 

I hope I have given you enough examples of why the 
Bureau needs accurate and complete data from our 
medical records. Ultimately, the information that we 
get from these records has an impact on the number of 
Medical Department personnel placed in our hospital 
systems, the types of major equipment that will be re- 
quired — and of course, at the bottom line, the funds the 
Bureau will receive from Congress to operate an effi- 
cient medical care system. 



I know that for you to do an efficient job three things 
are necessary: a quality control program, a con- 
tinuing program of training for your personnel, 
and constant updating on the latest developments in 
medicine and in methods of coding. As I look into the 



future, the demand for information from the medical 
record is going to be greater and greater. So we are 
depending on medical record administrators to assure 
us that we will have accurate and complete information 
from the medical record, as well as a well-trained staff 
in each of our hospitals. 

More than 20 years ago. Dr. Robert A. Moore, then 
vice chancellor of health professions at the University of 
Pittsburgh, stated: "Medical records and statistics bid 
fair to become the most important diagnostic and prog- 
nostic instruments of the future. Responsibilities for 
calibrating those instruments and for assuring their 
completeness, accuracy, and accessibility rest squarely 
on the shoulders of a well staffed and equipped record 
department in the clinic, the hospital, the public health 
department, the research organization." This state- 
ment is as true today as it was then, and I hope you will 
convey this message to your staffs when you get back to 
your hospitals. Please tell them how the work they do 
ties in with what is being done at the Bureau. (Of 
course, I am not forgetting how the output of the medi- 
cal record department meets the needs of our hospitals 
and affects the decisions that are made in each hospi- 
tal.) 

I know that each of you has many ideas on how medi- 
cal record administrators can be of even greater help to 
the Medical Department than they are today. We would 
like to have the benefit of your thinking and ideas, and 
hope that you will communicate with Mrs. Muriel 
Brandford, at the Naval Medical Data Services Center. 
We are depending on her to coordinate this type of in- 
formation, and she will be reporting to us at the Bureau 
at the Quality Assurance Committee meetings. 



Preventing Occupational Skin Disease 



Occupational dermatitis is gener- 
ally recognized as the most common 
type of occupational disease. 

Skin disorders account for ap- 
proximately half of all occupational 
illnesses. (Some 74,000 occupa- 
tional skin disease cases were re- 
ported in the U.S. in 1975.) But 
despite the high prevalence of these 
disorders, they are not the most 
serious or disabling health problem 
in the work place. 

Occupational dermatitis is usually 
preventable. The importance of 
personal cleanliness cannot be too 



strongly emphasized. 

When facility and process design 
cannot eliminate all contact with ir- 
ritants, the worker must use per- 
sonal protective equipment. Such 
equipment includes gloves, gaunt- 
lets, aprons, and boots. These 
items, along with face shields, are 
effective in most situations. 

Barrier creams and lotions may 
be used to supplement, but not to 
replace, personal protective equip- 
ment. The best protection is prob- 
ably provided by organic silicones, 
which repel water-dissolved irri- 



tants, including acids and alkalis. 

Protective-barrier agents should 
be applied to clean skin. When skin 
becomes soiled, both barrier and 
soil should be washed off and cream 
reapplied. 

Dermatitis occurs most frequently 
in new and young workers. It is 
important to educate them, before 
they begin work, to avoid washing 
with solvents and harsh soaps used 
for cleaning equipment. 

Institution of proper hygiene is 
the key to prevention of occupa- 
tional dermatitis. 



20 



U.S. Navy Medicine 



Professional 



Immersion Hypothermia 



LT William C. Donehue, MC, USNR CDR Edna L Peters, NC, USN 



While the civilian physician must be able to diagnose 
and treat victims of exposure hypothermia, particularly 
as it relates to the increasing number of winter-sports 
enthusiasts, the Navy physician must also be prepared 
to treat sailors and aviators who are victims of immer- 
sion hypothermia. These individuals have the misfor- 
tune of being lost from naval vessels or aircraft operat- 
ing in the world's cold-water regions. 

Man is, by nature, dependent upon a stable tempera- 
ture for his internal organs (core temperature). The 
normal thermoregulatory process maintains this tem- 
perature within a 1°F variation. Deviations from the 
normal core temperature can result in enzyme deactiva- 
tion, which will stop energy-producing reactions at the 
cellular level. 

Immersion in cold water is especially dangerous, be- 
cause great quantities of heat can be extracted from the 
victim's body in a very short time. The surrounding 
water quickly diffuses this extracted heat, thus acting 
as a heat sink of near infinite capacity. Man cannot, for 
example, maintain a stable core temperature during 
long-term exposure to water that has a temperature of 
75°F (24°C). 

Survival of the victim of cold-water immersion de- 
pends on the degree to which the core temperature is 
depressed. Body heat loss is contingent on five major 
factors: 

• the gradient between the victim's temperature and 
that of the water; 

• the amount of peripheral vasoconstriction, and 
thus the rate of transfer of heat from the core to the 
skin; 

• body insulation; 

• water motion; 

• duration of immersion. 



LT Donehue is currently serving as flight surgeon, Carrier Air 
Wing Eight, FPO New York 09501. 

CDR Peters is serving at the U.S. Branch Dispensary, Marine 
Corps Air Station, Iwakuni, Japan. 



Body responses to hypothermia 

Physiologically, the body exhibits two major methods 
of heat conservation. The first, peripheral vasoconstric- 
tion and limb blood flow shunting, serves to limit the 
blood's contact with the cold environment. The second, 
shivering and increased muscle tone, increases meta- 
bolic heat production. Together, these responses tend 
to maintain the core temperature within physiological 
limits as long as possible. 

The states of accidental hypothermia have been 
divided into the following three phases by Jessen and 
Hegelsten (i): 

• Excitation stage. This is the earliest stage of 
hypothermia. At this point, peripheral vasoconstriction 
and shivering occur. This stage occurs with core tem- 
peratures ranging from 93°F (34°C) to slightly below 
normal, 

• Adynamic stage. In this stage, muscular activity 
decreases while respiratory rate and cardiac minute 
volume increase. Core temperature during this stage is 
between 86°F (30°C) and 93°F (34°C). 

• Paralytie-stuporous stage. During this stage, the 
victim's bodily functions deteriorate dangerously. The 
prognosis is grim. Function of all systems — central 
nervous, respiratory, musculoskeletal, renal, and 
cardiovascular — approaches zero, and the patient may 
be mistaken for dead despite careful clinical examina- 
tion. Persistent ECG dysrhythmias and/or asystole may 
occur. EEG findings may be abnormal. 

Figure 1 further delineates the physiological changes 
associated with lowering of the body's core tempera- 
ture. It must be remembered that this diagram is only a 
general guide, not a specific statement of functional 
decay. 

Treatment 

Treatment of the hypothermic patient is crucial. The 
prognosis for the victim is entirely dependent upon cor- 
rect and timely application of proper treatment 
methods. 



Volume 70, January 1979 



21 



FIGURE 1 



uecreased 

level of consciousness "■ " 
Semicoma, 

euphoria possible — ■ 



£EG abnornj; 



Skeletal muscles flaccij 



EXCITATION PHASE 



^ - — Maxinuis shivering 

34 Jadykakic phase 

33 

33 4— Atrial fibrillati 



EEC activitv 

helow this point 




- ,n - Skeletal muscle rig idity 
29 



PASALVTIC-STLCCSCUS PHASE 



A-V dissociation 
Ventricular dysrhythmias 
Ventricular fibrillation 
fintractil 



In areas of potential cold exposure, hypothermia 
should be suspected even in the presence of other 
possible diagnostic entities that might be responsible 
for the patient's lowered level of consciousness. Resus- 
citation efforts must be started on each victim at once, 
even though signs of life may be absent because of the 
effects of cold. 

For many years the mainstay of hypothermia treat- 
ment has been rapid external rewarming. This can be 
accomplished by placing the victim in an immersion 
bath of warm water at 106°F - 108°F (41 °C ■ 42°C). The 
patient should be kept in the warm bath until he feels 
warm subjectively. (An adequate substitute for a bath- 
tub on a naval vessel is a liferaft LP-1, which can be 
inflated and filled with warm water.) 

"Rewarming shock," a paradoxical drop in core tem- 
perature associated with the early phase of warming, 
makes external rewarming extremely hazardous. The 
patient must be continuously monitored to ascertain his 
core temperature. Rectal probes or posterior pharyn- 
geal probes are suggested for this purpose, if available. 



It must be remembered that standard hospital ther- 
mometers seldom record below 96°F (36°C). The 
Standard Laboratory Thermometer, FSN 6685-444- 
3000, may be used to record lower temperatures, thus 
preventing a false sense of security. 

Recent research (2) and clinical experience now sug- 
gest that, whenever possible, internal rewarming — 
warming the core in advance of the body surface — is a 
technique permitting a more rapid return to normal 
body temperature without the ECG abnormalities and 
cardiac-output decreases found when the more tradi- 
tional methods are used. While many methods of in- 
ternal rewarming have been described, NAVMED 
P5052-29 suggests that the most practical means is 
peritoneal dialysis, using a 40°C dialysis solution and 
an arterial-venous shunt, connected to an external re- 
warming coil. Unfortunately, the equipment and skills 
these internal rewarming methods require are not 
present on aircraft carriers or stations having branch 
hospitals or dispensaries, 

With standard external rewarming methods in the 
very cold patient, 100% oxygen and/or ventilatory as- 
sistance may be needed until the patient warms suffi- 
ciently to maintain adequate ventilation on his own. 

While the patient is undergoing external rewarming, 
care should be taken to avoid unneeded physical manip- 
ulation, since the myocardium, when chilled, is very ir- 
ritable. Malignant dysrhythmias may supervene. All 
such cardiac arrhythmias will be refractory to cardiover- 
sion until the core temperature has exceeded 82.4°F 
(28°C). This will be an exceedingly troublesome prob- 
lem when associated with rewarming shock in a patient 
in whom internal rewarming techniques cannot be 
used. Further caution must be employed, when at- 
tempting cardioversion on a wet victim, to ensure that 
the resuscitation team does not receive electrical shock. 

Further therapy for the hypothermia victim includes 
intravenously administered bicarbonate to combat 
metabolic acidosis. The patient's urinary output should 
be monitored to detect fluid depletion due to "cold 
diuresis." Hypokalemia, probably due to an intracellu- 
lar sequestration of potassium, may be seen, but this 
usually does not require correction. 

The patient must be closely monitored for many 
hours and should be retained in sickbay until he or she 
is obviously fit for duty. Late complications of any of the 
involved organ systems are possible with profound 
hypothermia. These will be minimized by prompt diag- 
nosis, based upon a high index of suspicion, rapid re- 
warming, and careful monitoring of core temperature. 

References 

1. Jessen K, Hegelsten JO: Search and rescue service in Den- 
mark with special reference to accidental hypothermia. Aerospace 
Med 43:787-791, 1972. 

2. Technical Information Manual for Medical Corps Officers, 
Chapter 29, Cold Injury, NAVMED P-5052-29. Department of the 
Navy, Bureau of Medicine and Surgery, 1976, pp 11-14. 



2* 



U.S. Navy Medicine 



BUMED SITREP 



PA PROGRAM REINSTITUTED . . . Hospital corps- 
men in pay grades E-5 through E-9 are once again eligi- 
ble for selection for promotion to chief warrant officer, 
under the newly reestablished Physician's Assistant 
Program, 

Eligibility requirements include the following. Candi- 
dates must: 

• Be U.S. citizens, at least 21 years old but under 37. 

• Have a minimum GCT of 55 and ARI of 55, or a 
WK/AR of 110. 

• Possess a high school diploma or its equivalent. 

• Have no courts martial or civil convictions for two 
years. 

• Be recommended by their commanding officers. 

• Agree to 54 months of obligated service from the 
time PA training begins. 

On 10 January, a selection board will meet to pick the 
best qualified PA applicants for a class beginning train- 
ing at NRMC Portsmouth, Va., in April. 

A second group of PA applicants will be picked next 
month to enter training at NRMC San Diego in mid- 
summer. 

On successful conclusion of training, graduates will 
be appointed chief warrant officers. 

Applications for admission to the San Diego PA 
course should reach BUMED (Code 34) no later than 1 
February. Additional details on application require- 
ments are available in R010049Z Nov 78, NAVOP 
156/78. 



operational support — is more oriented toward Medical 
Department requirements. 
The new course will: 

• Familiarize attendees with the Defense decision- 
making environment, both nationally and internation- 
ally, so that they can better discharge their leadership 
roles by being more aware of salient contingencies and 
constraints. 

• Provide a working knowledge of DOD policy — and, 
in particular, health policy — as it relates to contingency 
planning and support. 

• Prepare each attendee to serve as a leader on the 
Navy medical support team, capable of planning and 
directing effective and efficient medical support, as re- 
quired by the operating forces. 

• Provide an update on Medical Department plans 
and programs, with emphasis on emergent trends of 
interest to top management. 

The new course covers a seven-week period and will 
be offered four times a year, beginning this month. 
Enrollment will not exceed 25 students per class. 

Candidates will be selected in BUMED from among 
those Medical Department officers currently in, or be- 
ing considered for assignment to, billets that have 
significant operational and/or contingency planning 
responsibilities. Student input will be determined 
solely on the basis of specified billet requirements 
identified by BUMED (Code 3). 



FOR FLIGHT SURGEONS . , . CNO Message 2719592 
Oct 78, Use of Privacy Act Statements in Aircraft 
Mishap Investigations, states that the individual re- 
questing information in the course of such an investiga- 
tion must make certain that the Privacy Act statement 
is made available to the responding individual. This 
includes information being sought for the MOR 
(OPNAV 3750/8A through 3750/81). The required 
statement is included in the CNO message. A supply of 
these statements should be produced locally and kept 
with the MOR forms. 



ADVANCED HEALTH POLICY, PLANNING COURSE 

... Up to 100 senior Medical Department officers in 
line for top leadership responsibilities will be selected 
annually for training in a new Advanced Health Policy 
and Planning Course to be conducted at the Naval 
School of Health Sciences, Bethesda, Md. 

The course is being inaugurated because of limited 
availability of training billets at such existing service 
schools as the Naval War College, and because of a 
need for training that — while retaining emphasis on 



MEDICAL EMERGENCY COMPUTER MODEL DE- 
VELOPED ... At the Naval Research Laboratory, Dr. 
Paul Richards, head of the Fleet Medical Support 
Project, has developed a computer model that can 
simulate the many complexities of an emergency medi- 
cal system in 10 minutes or less, at a cost of under S100. 

"A single mock drill conducted to simulate the medi- 
cal response to an aviation disaster at an airport, on the 
other hand, requires many months of preparation, a lot 
of manpower, and costs approaching $100,000," says 
Dr. Richards. "And even greater expenditures of time, 
money, and manpower would go into an exercise de- 
signed to test a military combat zone medical care 
system." 

The new computer model, called "NAMES II" (for 
Navy Amphibious Medical Evacuation Simulation), 
simulates medical treatment and evacuation of casual- 
ties within a combat zone. The model provides for vari- 
ous levels of casualty treatment facilities and a full 
range of evacuation options. 

NAMES II is currently being used by medical plan- 
ners in the military departments, but it is expected also 
to be of considerable interest to civilian organizations 
concerned with medical emergencies. 



Volume 70, January 1979 



*U.S.G0UERHrtENT PRINT1H6 OFF I CE ; 1 578 — 28 J-<l 71 / 1 I 



29 



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